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„ = MONITORING SYSTEM CERTIFICITION For Use By All Jurisdictions Within the State of California APR O-5 2018 Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A senarate certification or report must be oreoared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information FacilityName: Village West Marina Bldg.No.: Site Address: 6649 Embarcadero Drive City: Stockton, CA Zip: 95219 Facility Contact Person: Tim Fontiane Contact Phone No.: (209) 640-3556 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 3/6/2018 B. Inventory of Equipment Tested/Certified ChecktheappropHate boxes to indicates ecille equipment Inspected/serviced: Tank ID: Diesel Tank ID: 91 ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794380-344 ®Annular Space or Vault Sensor. Model: 794380-344 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: VMI 99LD-2000 ®Mechanical Line Leak Detector. Model: VMI 99LD-2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section Eon Page 2). Tank ID. Tank 1D: ❑In-Tank Gauging Prole. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector, Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/I ligh-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specilj equipment type and model in Section E on Page 2). Dispenser ID: 1 Dispenser ID: 2 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3 Dispenser ID: ®Dispenser Containment Sensor(s). Model: 794380-208 ❑Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floatts)and Chaw(s), ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). 'If the facility contains more tanks or dispensers.copy this funn. Include information for every tank and dispenser at the facility. C. Certification -1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report;(check all that apply): ® System set-up ® Alarm history report Technician Name(print): Guadalupe Sanchez Signatory __----,e e ! ' _, — Certification No.: A30138 License. No.: 1005444 /l�`v Testing Company Name: Diamond Petroleum Services, Inc. Phone No.:(925) 470-0803 Testing Company Address: 3619 King Ct.Antioch, CA 94509 Date of Testing/Servicing: 31612018 Page 1 of 4 Rev(2/08)